Download Painful Peripheral Neuropathy

Guidelines for the
Management of
Painful Peripheral
Diabetic
Neuropathy
Portsmouth Multidisciplinary Foot Team
2009
(Printing supported by Pfizer Limited)
Peripheral neuropathy is a complication of diabetes that is
caused by prolonged hyperglycaemia. It is estimated that 2040% of people with diabetes develop neuropathy although many
remain undiagnosed. Elevated blood glucose levels can cause
damage to the myelin sheath of the nerve. Loss of this protective
sheath leads to reduced sensation (painless peripheral
neuropathy). It may also lead to unwanted nervous stimulation
(painful peripheral neuropathy – PPN).
Risk factors for the development of neuropathy include age,
duration of diabetes, abnormal lipids, smoking and the presence
of other microvascular complications. The loss of sensation
associated with diabetic neuropathy significantly increases the
risk of foot ulceration.
PPN usually affects the feet but can also affect the hands.
Patients typically describe pins and needles (parasthesia),
numbness, itching, burning (despite feeling cold to touch), sharp
or shooting pains, restless legs and cramp-like discomfort. PPN
may persist for any period of time from a few weeks to a many
years. Sudden changes in glycaemic control can exacerbate
symptoms. After the first few months the pain tends to gradually
improve but the sufferer may be left with painless peripheral
neuropathy.
This guideline has been designed to assist Health Care
Professionals in the management of neuropathic pain.
Further information regarding the numbered points within
the flow chart can be found over the page.
The guideline can also be found at
www.porthosp.nhs.uk/diabetesendo.html
Diagnosis (1)
Explanation and Reassurance.
Consider Psychological support
and / or treatment of depression (2)
Discuss importance of foot
care and wear.
Refer to Advanced Podiatry
team (3)
Consider other reversible
causes such as alcohol and
vitamin B12 deficiency
Review glycaemic control.
Aim for a target HbA1c of
less than 7.5% (4)
Refer for Physiotherapy if
required
Consider referral into the Specialist Foot Care Service at any stage (5)
Prescribe simple analgesia eg Paracetamol (6
weeks or review sooner if distressed) (6)
Superficial Symptoms (eg burning, itching, pins
& needles & numbness)
Try Capsaicin cream – apply 3-4 times daily
to the affected area. Alternatively consider
Flexitol cooling gel, Urgo plaster spray or
Elastoplast spray. Putting feet in a bucket of
cold water can also ease symptoms (6)
Deep Symptoms (eg sharp shooting pain)
Unless contra-indicated add or start Tricyclic
Antidepressants (TCIs) – Amitriptyline or
Imipramine.
Starting dose = 10mg at night. For dose titration
see patient guidelines at the end of this
document (6)
Unless contra-indicated add or start Gapapentin. Starting dose 300mgs titrating according to effect.
Maximum dose = 1.8g daily.
If unable to tolerate Gabapentin try Pregabalin (Lyrica). Starting dose = 150mg daily in 2-3 divided doses.
Titrate according to effect. Maximum dose 600mg daily in 2-3 divided doses.
See BNF for full details (6)
Unless contra-indicated add or start Duloxetine (not in combination with TCIs).
Starting dose = 60mg once daily.
See BNF for full details (6)
Consider other drug therapies (e.g.
Tramadol, Oxycontin, Lidocaine Patches)
See BNF for full details (6)
1. Diagnosis
In diagnosing PPN the foot pain must be differentiated from foot pain from other sources (see
pain classification chart). In PPN the pain is usually worse at rest, it does not tend to be
related to activity and is usually bilateral. Diagnosis is made by taking a careful history of
symptoms and carrying out a physical examination. Nerve conduction studies are not
considered necessary. Sensation loss with a 10g monofilament will usually be demonstrated
apart from in those patients picked up with early acute painful symptoms that relates to a
sudden change in glycaemic control. Free training on diabetic foot risk assessment can be
arranged by contacting the Portsmouth Training Team electronically [email protected]
Claudication
Where Felt?
Symptoms
Described
As…
Relieved
By….
Feels….
Pulses
Present?
Buttocks,thighs or
calf muscles,
usually one
or both legs
Worse on waking
Sharp / cramp like
pains
Rest
Cold
Diminished or
absent
Peripheral Vascular
Disease
Forefoot and / or lower
Limbs –
one or both legs
Neuropathic
Can occur any time.
Worse in bed or with
legs elevated. Cramp,
burning, aching
Legs hanging down
Toes and bottom of feet –
usually both. Legs – lower
to upper (and
Sometimes hands)
Burning, pins and needles,
stabbing, walking on hot
coals or marbles. Can be
constant but worse at night
Standing, walking around
Cold
Diminished or absent
Warm to touch / cold
Normal to bounding
2. Psychological Support
The pain associated with diabetic neuropathy can be emotionally and physically exhausting
and sufferers often benefit from a clear explanation of the condition. Psychological
complications may include feelings of isolation, frustration (from being unsure of the cause or
a lack of a clear management plan) and depression (due to a lack of sleep and the strain of
living with chronic pain).
3. Foot Care and Podiatry
Patients suffering with neuropathic pain are at increased risk of foot ulceration and its
complications and should receive appropriate advice regarding foot care and footwear. A foot
care advice sheet can be found at the end of this document.
Patients should be referred to the podiatry service for ongoing assessment and prevention
plan.
Routine Podiatry Referrals:
Refer to local Podiatry Clinic.
Urgent Podiatry Referrals:
All podiatry clinics will accept urgent referrals. The Healthy Living Centre has a dedicated
foot ulcer/diabetes clinics Tel – 02392 381093 to arrange referral. Telephone advice is
available 9am-5pm from Sharon Tuck Tel – 07810 656019 and the Podiatry rapid response
service. Rapid response is for assessment, advice and intervention for new or housebound
patients with foot infection, new ulceration or sudden onset of foot pain. Calls will be
returned within 2 hours and appropriate action/appointment offered within 48 hours.
Tel – Portsmouth City - 07770581507
Fareham and Gosport – 07770581370
East Hants – 07770581460
Ward Podiatry Referrals:
Fax referral form to Battenburg Avenue Clinic – 02392 672258 or Tel (queries only) – 02392
670346
4. Glycaemic Control
Optimal glycaemic control may help to ease symptoms and prevent further deterioration,
although sudden improvements should be avoided as they may lead to insulin neuritis and
increased pain, or pain when none has been experienced before. Patients should aim for home
blood glucose levels of between 4-7mmols before meals and 7-10mmols 2 hours after.
Locally, the target for HbA1C is set at 7.5% or below and tighter control is advocated in the
presence of diabetic complications.
5. Specialist Referral
Referral into the Specialist Diabetes Foot Care Service can be made at any point but would
typically be recommended if Amitriptyline and / or topical therapies had been unsuccessful.
The following services are available to patients:
Painful Peripheral Diabetic Neuropathy Education Groups –
These are one off structured education sessions that aim to enable people with painful
peripheral neuropathy to gain a better understanding of their condition – its cause, available
treatments and associated risks. They also aim to help people make informed decisions about
how to cope with the disease and ensure that they are aware of support services available to
them. More information can be found in Holland E, Bryan H, Skinner C and Robinson K
(2005) Group education for painful peripheral diabetic neuropathy. Journal of Diabetes
Nursing 9 (9): 342 – 345.
Please direct referrals to Kate Marsden at the Diabetes Centre.
Joint Medical / Podiatry Clinic –
This is held at the Diabetes Centre on a weekly basis.
Please direct referrals to Dr D R Meeking at the Diabetes Centre.
Diabetes Centre: Queen Alexandra Hospital
Southwick Hill Road
Portsmouth
Hampshire
PO6 3LY
Tel - 02392 286260
Fax – 02392 286791
6. Drug Treatment
Treatment of PPN often requires a variety of therapies and frequently symptoms will not be
completely alleviated. Patients should be informed that treatment aims to reduce pain by
around 50% and improve quality of life, sleep and mobility. Topical treatments such as
Flexitol Cooling Gel, and plaster sprays are often helpful for superficial symptoms. Capsaicin
Cream can also be used but is not suitable if the pain is over a large surface area. Initially
patients may experience an increase in pain but with regular application this should diminish.
If topical treatments have not worked or are not deemed appropriate then systemic treatments
must be considered. Tricyclic antidepressants (Amitriptyline and Imiprimine) and
anticonvulsants (Gabapentin and Pregabalin) are the drugs most commonly prescribed.
Duloxetine has recently been licensed for the treatment of neuropathic pain. Tramadol,
Oxycontin and Lignocaine Patches may be prescribed if the patient continues to suffer.
Foot Care and Footwear Advice for Feet with Peripheral
Neuropathy
Daily Care:
Daily Visual checks
Visual
checks
Look
for any
new injury and seek help
Look for any new injury and seek help
Daily Skin Care
Skin Care
Wash
and
carefully
Wash
anddry
dry carefully
Apply
moisturiser to
areas
of dry
Apply
moisturiser
toany
any
areas
ofskin.
dry skin.
Nail Care
Best attended to frequently as part of foot care routine
Cutting nails may be difficult and it is possible to damage the skin
Weekly filing is the safest and easiest way to deal with toenails
Footwear
Should fit well and be foot shaped
Shoes with adjustable fastening are best
Shoes should not need to be worn in
Remember
People with sensation loss may not notice minor trauma
Caution with hot water bottles or barefoot walking
People may be unaware of their degree of sensation loss
Tight footwear or hosiery could be harmful
Wearing thicker socks/stockings to keep warm in winter may make shoes
too tight
Printable version available at www.porthosp.nhs.uk/diabetesendo.html
Patient Guidelines for increasing Amitriptyline doses for
The Management of Painful Diabetic Peripheral Neuropathy
Portsmouth Hospitals NHS Trust Diabetes Centre
Tel No : 023 92 286260
Week 1 - START-
Amitriptyline Hydrochloride
10 mg tablet to be taken at bedtime
Week 2
If no improvement in symptoms -
Increase dose to 20 mg
Week 3
If no improvement in symptoms –
Increase dose to 50 mg
Week 4
If no improvement in symptoms –
Increase dose to 75 mg
Week 8
If no improvement in symptoms Seek further advice .See contact
numbers below.
If any increased dose cannot be tolerated then return to your previous dose and
continue for 4 weeks. It may take some time for this treatment to get into your
system to be effective.
Mild side effects of this drug are:
Drowsiness, constipation, blurred vision, dry mouth, sweating - these side effects can
persist into the next day at the start of your treatment however most of these side effects
will fade if you continue to take the tablets.
If however you have difficulty in passing water, confusion, rashes and heart palpitations then :
Stop the tablets and see your GP if not settling immediately.
If you are concerned / worried about your treatment you may
 Phone the ‘Medicines Information Dept’ at Q.A.H on 023 92286632
 Or see your GP.
 Or phone the diabetes Nurse specialist for further advice on 023 92 286260
Approved by Diabetes Team /DRM/ELH/ Pharmacy Dept 02.10.01 Revised15/03/04
Printable version available at www.porthosp.nhs.uk/diabetesendo.html